435 S ANAHEIM HILLS RD (4)Permit Types .
BLD ELE MEC PLM
X
`-ftitnit Number. BLD2023-01103
Issued: 03/07/2023
www.anaheim.neUbuilding
(714)765-0626
Quarter Section: 192
CITY OF ANAHEIM
BUILDING DMSION-- —
200 S. ANAHEIM BL 6 .
(7141 765 - 5153
Site Address: 435 S ANAHEIM HILLS RD, ANAHEIM, CA 92807
Legal Description: P BK 245 PG 11 PAR 1 P.M. 245-11 POR PARCEL 1
APN:36347202
WORKER'S COMPENSATION DECLARATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEYS FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for worker's compensation, issued by the Director of Industrial Relations as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
I have and will maintain workers compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
this permit is issued. My worker's Compensation insurance carrier and policy are:
Cartier: Policy No.: Expiration Date:
Name of Agent: Phone No.:
1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the
v ` worker's compensation laws of California, and agree that, if I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code shal rthwilh empty with those provisions.
07/67 2
SignatApf Applicantf Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit Is Issued
(Sec.3097.Civ.C):
Lenders Name:
Lenders Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professio a nd my license is iq7*
11�' �3 0� Z
Contractor Sig at re Date
NUMBER EXPIRATION DATE LICENSE TYPE (S)
1093626 07/31/2024